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Ministerul Sntii al Republicii Moldova

DOCUMENTAIE MEDICAL
Formular
nr.

Aprobat de MS al RM

___________________________________________________
denumirea instituiei

088/e
nr. 828 din 31.10. 2011

TRIMITERE LA CONSILIUL DE EXPERTIZ MEDICAL A VITALITII



1. Numele, prenumele bolnavului______________________________________________________________________
, ,
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Numr de identificare ____________________________________________________________________________

2. Data naterii _______________________________________________________ Sex________________________

3. Adresa la domiciliu_______________________________________________________________________________

4. Invalid de gradul _________________ 5. Locul de munc_______________________________________________


6. Adresa locului de munc__________________________________________________________________________

7. Profesia_______________________________________ 8. Funcia_______________________________________

9. Denumirea instituiei medico-sanitare care a trimis bolnavul______________________________________________


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10. Supravegheat de instituia medico-sanitar care a trimis de la ___________________________________20____

11. N-a lucrat din cauza bolii ultimele 6 luni
6
De la i pn la ce zi a lunii

Denumirea bolii

12. Schimbarea profesiei sau a condiiilor de munc n ultimul an



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13. Istoricul bolii actuale (debutul, dezvoltarea, evoluia, datele acutizrilor, msurile curativ-profilactice efectuate)
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14.*) Starea bolnavului la trimitere la C E M V (acuzele, starea general, starea pielii, esutului conjunctiv-adipos, muchilor,
oaselor, articulaiilor, organelor aparatului respirator, circulator, digestiv, genito-urinar i a sistemului neuro-psihic)
(, , , ,
, , , , , , - )
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*) punctul 14 se completeaz de medicul de familie i cel puin 2 medici specialiti de profil


14 2
3

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15. Investigaiile de laborator i instrumentale _____________________________________________________________



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16.

Diagnosticul la trimitere la CEMV:


:
a) diagnosticul de baz (pentru bolnavii de TBC- caracteristica clinic conform clasificaiei acceptate)
( - , )

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b) boli concomitente____________________________________________________________________________

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) complicaii________________________________________________________________________________

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17. Trimiterea la C E M V n baza


(a specifica)
()

1. Existena semnelor de invaliditate


3. Reexaminare nainte de termen


2. Expirarea termenului invaliditii-reexaminare


-

4. Prelungirea certificatului de concediu medical


L..
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Preedintele CMC

Membrii CMC

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________ ______________________________20___________
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Ministerul Sntii al Republicii Moldova


DOCUMENTAIE MEDICAL

___________________________________________________

Formular

denumirea instituiei

nr. 088/e

Aprobat de MS al RM

nr. 828 din 31.10. 2011

AVIZUL INSTITUIEI MEDICO-SANITARE PRIVIND DECIZIA


CONSILIULUI DE EXPERTIZ MEDICAL A VITALITII

1. Denumirea instituiei medico-sanitare unde se expediaz avizul i adresa



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2. Numele, prenumele bolnavului _______________________________________________________________________


, ,
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Numr de identificare _________________________________________________________________________________________

3. Data examinrii la C E M V___________________________________________________________________________

4. Procesul verbal nr. ______________________________________________________________________________
A
5. Diagnosticul C E M V______________________________________________________________________________

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6. Concluzia C E M V_______________________________________________________________________________

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7. Locul de munc recomandat _______________________________________________________________________



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L..
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Data trimiterii

Preedintele C E M V

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